Prescott Animal Hospital (PAH Holdings PC) Annual Report (Arizona Corporation Commission) (2018)

STATE OF ARIZONA
ee CORPORATION COMMISSION

244
CORPORATION ANNUAL REPORT aaa
& CERTIFICATE OF DISCLOSURE
DUE ON OR BEFORE 3/29/2018 FILING FEE 45.00

PLEASE READ ALL INSTRUCTIONS. The following information is required by A.R.S. §§10-1622 & 10-11622 for all corporations
organized pursuant to Arizona Revised Statutes, Title 10. The Commission’s authority to prescribe this form is A.R.S. §§ 10-121(A)
& 10-3121(A). YOUR REPORT MUST BE SUBMITTED ON THIS ORIGINAL FORM. Make changes or corrections where necessary.
Information for the report should reflect the current status of the corporation.

08713675

1. PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C.
1318 IRON SPRINGS RD
PRESCOTT, ARIZONA 86305

Business Phone: (Business phone is optional.)

State of Domicile: Az Type of Corporation: PROFESSIONAL
2. Statutory Agent: MICHAEL L RUBIN Statutory Agent's Street or Physical Address:
Mailing Address: 2830 ANDERSON RD Physical Address:
City, State, Zip: PRESCOTT, ARIZONA 85303 City, State, Zip: .

ACC USE ONLY :

: If appointing a new statutory agent, the new agent MUST consent to that ;
Fae: 45.00 : appointment by signing below. Note that the agent address must be in Arizona.

Penalty: |, (individual) or We, (corporation or limited liability company) having been designated the new Statutory Agent, do
‘hereby consent to this appointment until my removal or resignation pursuant to law.

Reinstate:

Expedite: : '

Resubmit: : Signature of new Statutory Agent

Printed Name of new Statutory Agent

3. Secondary Address:

(Foreign Corporations are REQUIRED ,

to complete this section).

4. Character of Business:

VETERINARY MEDICINE/ANIMAL CARE

Received: 3/29/2018 6:04:49 PM

AR:0046 Arizona Corporation Commission
Rev. 8/2016 Corporations Division

Page 2
5. CAPITALIZATION: (For-profit Corporations and Business Trusts are REQUIRED to complete this section.)

Business trusts must indicate the number of transferable certificates held by trustees evidencing their beneficial interest in the trust estate.

5a. Please examine the corporation's original Articles of Incorporation for the amount of shares authorized.

Number of Shares/Certificates Authorized Class Series Within Class (if any)
100000.00 COMMON
0.00

5b. Review all corporation amendments to determine if the original number of shares has changed. Examine the corporation's minutes for the
number of shares issued.

Number of Shares/Certificates Issued Class Series Within Class (if any)
2000.00 COMMON
0.00
6. SHAREHOLDERS: (For-profit Corporations and Business Trusts are REQUIRED to complete this section.)

List shareholders holding more than 20% of any class of shares issued by the corporation, or having more than a 20% beneficial interest in the
corporation.

Name: KENNETH SKINNER Name: BRYAN NOLTE
Name: CAMERON DOW Name:

7. OFFICERS:

Name Title Date Taking Office
DR KENNETH C SKINNER PRESIDENT/CEO 1/1/2013

783 PEPPERMINT WAY, PRESCOTT, ARIZONA 86305

DR CAMERON S DOW VICE-PRESIDENT 5/4/2015

793 GRAPEVINE LANE, PRESCOTT, ARIZONA 86305

DR BRYAN K NOLTE VICE-PRESIDENT 1/1/2003

7685 N DEERFIELD DR, PRESCOTT, ARIZONA 86305
8. DIRECTORS:

Name Date Taking Office
DR CAMERSON S DOW 5/4/2015

793 GRAPEVINE LN, PRESCOTT, ARIZONA 85601

DR BRYAN K NOLTE 1/1/2000

7685 N DEERFIELD DR, PRESCOTT, ARIZONA 86305

DR KENNETH C SKINNER 1/1/1997

783 PEPPERMINT WAY, PRESCOTT, ARIZONA 86305

AR:0046 Arizona Corporation Commission
Rev. 8/2016 Corporations Division

9. FINANCIAL DISCLOSURE (A.R.S.§10-11622(A)(9)) Rage?

Nonprofits — financial disclosure is no longer required. Cooperative marketing associations — must submit a financial statement. All other
types of corporations are not required to file a financial statement.

ONLY NONPROFIT CORPORATIONS MUST ANSWER THIS QUESTION:
9A. MEMBERS (A.R.S. §10-11622(A)(6)) This corporation DOES [__] DOES NOT [ ] have members.
10. CERTIFICATE OF DISCLOSURE (A.R.S. §§10-202(D), 10-3202(D),10-1622(A)(8) & 10-11622(A)(7))

A. Has any person who is currently an officer, director, trustee, incorporator, or who, in a For-profit corporation, controls or holds more than 10% of the issued
and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation been:
Ls Convicted of a felony involving a transaction in securities, consumer fraud or antitrust in any state or federal jurisdiction within the five year period
immediately preceding the execution of this certificate?
2. Convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses or restraint of trade or
monopoly in any state or federal jurisdiction within the five year period immediately preceding execution of this
certificate?
3. Subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the five year period immediately preceding
execution of this certificate where such injunction, judgment, decree or permanent order involved the
violation of:
(a) fraud or registration provisions of the securities laws of that jurisdiction, or
(b) the consumer fraud laws of that jurisdiction, or
(c) the antitrust or restraint of trade laws of that jurisdiction?

One box must be marked: YES a No|x |

If "YES" to A, the following information must be submitted as an attachment to this report for each person subject to one or
more of the actions stated in Items 1 through 3 above.

1. Full birth name. 5. Date and location of birth.

2. Full present name and prior names used. 6. The nature and description of each conviction

3. Present home address. or judicial action; the date and location; the court

4. All prior addresses for immediately preceding 5 year and public agency involved; and the file or
period. cause number of the case.

B. Has any person who is currently an officer, director, trustee, incorporator, or who, in a For-profit corporation, controls or holds over 20% of the issued and
outstanding common shares, or 20% of any other proprietary, beneficial or membership interest in the corporation, served in any such capacity or held a 20%
interest in any other corporation on the bankruptcy or receivership of that other corporation?

One box must be marked: YES [| No|x |

If “YES” to B, the following information must be submitted as an attachment to this report for each corporation subject to the
statement above.

(a) Name and address of each corporation and the persons involved.

(b) State(s) in which it: (i) was incorporated and (ii) transacted business.

(c) Dates of corporate operation.

11. STATEMENT OF BANKRUPTCY OR RECEIVERSHIP (A.R.S. §§ 10-1623 & 10-11623)
A. Has the corporation filed a petition for bankruptcy or appointed a receiver? One box must be marked: YES [| NO

If “Yes” to A, the following information must be submitted as an attachment to this report:

1. All officers, directors, trustees and major stockholders of the corporation within one year of filing the petition for bankruptcy or
the appointment of a receiver. If a major stockholder is a corporation, the statement shall list the current president, chairman of
the board of directors and major stockholders of such corporate stockholder. “Major stockholder” means a shareholder
possessing or controlling twenty per cent of the issued and outstanding shares or twenty per cent of any proprietary, beneficial
or membership interest in the corporation.

2. Whether any such person has been an officer, director, trustee or major stockholder of any other corporation within one year of
the bankruptcy or receivership of the other corporation. If so, for each such corporation give:

(a) Name and address of each corporation;
(b) States in which it: (i) was incorporated and (ii) transacted business.
(c) Dates of operation.

12. SIGNATURES: |Annual Reports must be signed and dated by at least one duly authorized officer or they will be rejected.

| declare, under penalty of perjury, that all corporate income tax returns required by Title 43 of the Arizona Revised Statutes have been filed with the
Arizona Department of Revenue. | further declare under penalty of perjury that | (we) have examined this report and the certificate, including any
attachments, and to the best of my (our) knowledge and belief they are true, correct and complete.

Name: DR KENNETH C SKINNER Date:3/29/2018
Signature: DR KENNETH C SKINNER
Title: PRESIDENT/CEO

(Signator(s) must be duly authorized corporate officer(s) listed in section 7 of this report.)

AR:0046 Arizona Corporation Commission
Rev. 8/2016 Corporations Division